The 2010 Health Care Reform Act: A Potential Opportunity to Advance Cancer Research by Taking Cancer Personally

Patient Enrichment for Precision-Based Cancer Clinical Trials: Using Prospective Cohort Surveillance as an Approach to Improve Clinical Trials

Technological advances have led to the identification of biomarkers and development of novel target-based therapies. While some novel therapies have improved patient outcomes, the prevalence and diversity of biomarkers and targets in patient populations, especially patients with cancer, has created a challenge for the design and performance of clinical trials. To address this challenge we propose that prospective cohort surveillance of patients may be a solution to promote clinical trial matching for patients in need.

Strategies for Appropriate Patient-centered Care to Decrease the Nationwide Cost of Cancers in Korea

In terms of years of life lost to premature mortality, cancer imposes the highest burden in Korea. In order to reduce the burden of cancer, the Korean government has implemented cancer control programs aiming to reduce cancer incidence, to increase survival rates, and to decrease cancer mortality. However, these programs may paradoxically increase the cost burden. For examples, a cancer screening program for early detection could bring about over-diagnosis and over-treatment, and supplying medical services in a paternalistic manner could lead to defensive medicine or futile care. As a practical measure to reduce the cost burden of cancer, appropriate cancer care should be established. Ensuring appropriateness requires patient-doctor communication to ensure that utility values are shared and that autonomous decisions are made regarding medical services. Thus, strategies for reducing the cost burden of cancer through ensuring appropriate patient-centered care include introducing value-based medicine, conducting cost-utility studies, and developing patient decision aids.

Quality assessment and improvement of nationwide cancer registration system in Taiwan: a review

Cancer registration provides core information for cancer surveillance and control. The population-based Taiwan Cancer Registry was implemented in 1979. After the Cancer Control Act was promulgated in 2003, the completeness (97%) and data quality of cancer registry database has achieved at an excellent level. Hospitals with 50 or more beds, which provide outpatient and hospitalized cancer care, are recruited to report 20 items of information on all newly diagnosed cancers to the central registry office (called short-form database). The Taiwan Cancer Registry is organized and funded by the Ministry of Health and Welfare. The National Taiwan University has been contracted to operate the registry and organized an advisory board to standardize definitions of terminology, coding and procedures of the registry's reporting system since 1996. To monitor the cancer care patterns and evaluate the cancer treatment outcomes, central cancer registry has been reformed since 2002 to include detail items of the stage at diagnosis and the first course of treatment (called long-form database). There are 80 hospitals, which count for >90% of total cancer cases, involved in the long-form registration. The Taiwan Cancer Registry has run smoothly for >30 years, which provides essential foundation for academic research and cancer control policy in Taiwan.

Collaborative biomedicine in the age of big data: the case of cancer

Biomedicine is undergoing a revolution driven by high throughput and connective computing that is transforming medical research and practice. Using oncology as an example, the speed and capacity of genomic sequencing technologies is advancing the utility of individual genetic profiles for anticipating risk and targeting therapeutics. The goal is to enable an era of “P4” medicine that will become increasingly more predictive, personalized, preemptive, and participative over time. This vision hinges on leveraging potentially innovative and disruptive technologies in medicine to accelerate discovery and to reorient clinical practice for patient-centered care. Based on a panel discussion at the Medicine 2.0 conference in Boston with representatives from the National Cancer Institute, Moffitt Cancer Center, and Stanford University School of Medicine, this paper explores how emerging sociotechnical frameworks, informatics platforms, and health-related policy can be used to encourage data liquidity and innovation. This builds on the Institute of Medicine’s vision for a “rapid learning health care system” to enable an open source, population-based approach to cancer prevention and control.

Personalizing oncology: perspectives and prospects

This article provides an overview of the research, beginning a century ago, that has led to the current use of genomically informed methods for selection of targeted therapies to treat individual patients with cancer--so-called precision cancer medicine. Until 1980, most research on cancer therapy was not targeted in the sense we use the word today. Since then, there has been an acceleration in research identifying genetic and molecular targets and in clinical trials using biomarkers that identify the presence of genetic or molecular markers in a patient's cancer to select appropriate targeted therapy. This approach has been made possible by increased knowledge of the genetic pathogenesis of cancer and by increased capacity to sequence genes and genomes in clinically useful timeframes and at a reasonable cost. However, many challenges and pitfalls remain in selecting optimal targets, interpreting data on genetic aberrations, designing effective targeted drugs and antibodies, dealing with resistance to treatments, identifying appropriate combinations of therapies, and performing the complex clinical trials that are required. Future clinical research with experimental targeted agents is likely to be more informative because of appropriate preselection of patients enrolled onto trials and performance of genetic and molecular studies on specimens of a patient's cancer before and after treatment.

Implementing personalized medicine in a cancer center

In 2006, the Moffitt Cancer Center partnered with patients, community clinicians, industry, academia, and 17 hospitals in the United States to begin a personalized cancer care initiative called Total Cancer Care. Total Cancer Care was designed to collect tumor specimens and clinical data throughout a patient's lifetime, with the goal of finding "the right treatment, for the right patient, at the right time." Because Total Cancer Care is a partnership with the patient and involves collection of clinical data and tumor specimens for research purposes, a formal protocol and patient consent process was developed, and an information technology platform was constructed to provide a robust "warehouse" for clinical and molecular profiling data. To date, more than 76,000 cancer patients from Moffitt and consortium medical centers have been enrolled in the protocol. The Total Cancer Care initiative has developed many of the capabilities and resources that are building the foundation of personalized medicine.

Highly-integrated lab-on-chip system for point-of-care multiparameter analysis

A novel innovative approach towards a marketable lab-on-chip system for point-of-care in vitro diagnostics is reported. In a consortium of seven Fraunhofer Institutes a lab-on-chip system called "Fraunhofer ivD-platform" has been established which opens up the possibility for an on-site analysis at low costs. The system features a high degree of modularity and integration. Modularity allows the adaption of common and established assay types of various formats. Integration lets the system move from the laboratory to the point-of-need. By making use of the microarray format the lab-on-chip system also addresses new trends in biomedicine. Research topics such as personalized medicine or companion diagnostics show that multiparameter analyses are an added value for diagnostics, therapy as well as therapy control. These goals are addressed with a low-cost and self-contained cartridge, since reagents, microfluidic actuators and various sensors are integrated within the cartridge. In combination with a fully automated instrumentation (read-out and processing unit) a diagnostic assay can be performed in about 15 min. Via a user-friendly interface the read-out unit itself performs the assay protocol, data acquisition and data analysis. So far, example assays for nucleic acids (detection of different pathogens) and protein markers (such as CRP and PSA) have been established using an electrochemical read-out based on redoxcycling or an optical read-out based on total internal reflectance fluorescence (TIRF). It could be shown that the assay performance within the cartridge is similar to that found for the same assay in a microtiter plate. Furthermore, recent developments are the integration of sample preparation and polymerase chain reaction (PCR) on-chip. Hence, the instrument is capable of providing heating-and-cooling cycles necessary for DNA-amplification. In addition to scientific aspects also the production of such a lab-on-chip system was part of the development since this heavily affects the success of a later market launch. In summary, the Fraunhofer ivD-platform covers the whole value chain ranging from microfluidics, material and polymer sciences, assay and sensor development to the production and assembly design. In this consortium the gap between diagnostic needs and available technologies can be closed.

Value and cancer care: toward an equitable future

Health care expenses in the United States are increasing inexorably. At the current rate of growth, it is anticipated that 20% of the gross national product will consist of health-related expenditures within the next decade. Cancer is the second leading cause of death in the United States, and it is increasing in prevalence because of the aging of the population and the limited number of successful prevention strategies. As the biological characteristics of cancer come into sharper focus, targeted therapies are being developed that offer the promise of increased clinical benefit with fewer toxicities than are associated with conventional treatment. Although spectacular successes are infrequent with this approach, to date, the majority of targeted therapies are modestly effective at best, and extremely costly. This observation suggests that a broadly acceptable definition of value in a cancer therapeutic agent is not at hand, but is sorely needed from the vantage points of the patient and society. A corollary issue of enormous import is how to equitably distribute the health care dollar in the service of achieving the greatest good for the greatest number. Although cancer is responsible for only 5% of the health care budget, its cost is increasing and it can be viewed as paradigmatic when contemplating the problem of equity in health care. Here, a number of concepts are discussed that focus on this goal and its implications for the cancer patient and society at large.

Making the investigational oncology pipeline more efficient and effective: are we headed in the right direction?

Advances in our knowledge of the molecular mechanisms involved in cancer biology have contributed to an increase in novel target-specific oncology therapeutics. Unfortunately, clinical development of new drugs is an expensive and slow process, and the patient and financial resources needed to study the vast number of potential therapies are limited, requiring novel approaches to clinical trial design and patient recruitment. In addition, traditional efficacy endpoints may not be adequate to fully determine the therapeutic worth of the new classes of targeted agents. In this new era of drug development, it has become increasingly clear that new clinical trial design paradigms that examine nontraditional endpoints have become necessary to assist in prioritizing the development of the most promising agents. It is also vital that individual patient management be considered, and the subpopulations of patients most likely to derive benefit or experience harm from a new therapy be identified as early as possible. Phase I and II clinical trials allow investigators doing clinical research the opportunity to define these critical endpoints and subpopulations early on, before conducting large-scale randomized phase III clinical trials, which require an abundance of financial and patient resources.

The impact of insurance on access to cancer clinical trials at a comprehensive cancer center

PURPOSE

Cancer patients at Johns Hopkins undergo insurance clearance to verify coverage for enrollment to interventional clinical trials. We sought to explore the impact of insurance clearance on disparities in access to cancer clinical trials at this urban comprehensive cancer center.

EXPERIMENTAL DESIGN

We evaluated the frequency of insurance-based denial of access to cancer clinical trials over a 5-year period after initiation of a formal insurance clearance process. We used a case-control design to compare demographic and clinical parameters of patients denied or approved for clinical trials participation by their insurance company in a 3-year interval.

RESULTS

From July 2003 to July 2008, insurance requests for clinical trial participation were submitted on 4,617 consented cancer patients at Johns Hopkins. A total of 628 patients (13.6%) with health insurance were denied therapeutic trial enrollment owing to lack of insurance coverage for participation. A total of 254 patients denied enrollment from 2005 to 2007 were selected for further analysis. Two-hundred sixty randomly selected patients approved for clinical trial participation served as controls. Patients approved were on average older (59.2 versus 54.9 years) than patients denied (P = 0.0001). Residents of Pennsylvania, which lacks a state law mandating cancer clinical trial coverage for residents, were overrepresented among the denied patients (P = 0.0009). No statistically significant variance in the likelihood of insurance denial was found on the basis of sex, race, stage of disease, or presence of comorbidities.

CONCLUSIONS

Denial of access to therapeutic clinical trials, even among insured patients, is a significant barrier to clinical cancer research. This barrier spans racial, ethnic, and gender categories.